Precision Dental Group New Patient Form
330.278.1061 | 1315 Ridge Road, Hinckley OH 44233 | HinckleyPrecisionDental.com
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First, Middle and Last Name *
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Social Security Number
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Date of Birth *
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Gender *
Status *
CONTACT INFORMATION
Street Address *
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City, State, Zip *
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Home Phone *
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Cell Phone *
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Occupation *
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Employer *
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Business Address
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Business Phone *
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Emergency Contact First & Last Name *
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Emergency Contact Phone *
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Whom shall we thank for referring you *
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If you checked "Referral" or "Other" above, kindly share that person's name or other source
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PRIMARY DENTAL INSURANCE
Person responsible for account *
The following questions pertain to the Primary Insured or Person Responsible. If you do not have insurance, simply enter "NA"
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Relationship to patient *
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Date of Birth *
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Social Security Number
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Home Street Address *
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City, State, Zip *
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Home Phone *
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Employer *
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Employer *
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Business Street Address, City, State, Zip *
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Business Phone *
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Occupation *
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Insurance Company *
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Insurance Company Address
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Subscriber ID# *
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Group # *
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ADDITIONAL INSURANCE
Insured Name *
The following questions pertain to the Insured. If there is no additional insurance, simply enter NA
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Relationship to Patient *
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Date of Birth *
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Social Security Number
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Home Address, City, State, Zip *
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Home Phone *
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Insured Employer *
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Business Address, City, State, Zip *
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Business Phone *
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Occupation
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Insurance Company *
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Insurance Company Address
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Subscriber ID# *
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Group # *
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DENTAL HISTORY
Previous Dentist Name *
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City/State *
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Date of last dental visit *
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Date of last x-rays
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How often do you floss? *
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How often do you brush? *
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Please check all that apply *
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MEDICAL HISTORY
Primary Care Physician's Name *
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Date of Last Visit *
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Currently under medical treatment? *
Any serious illnesses or operations? *
If yes, please describe
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Currently taking medications? *
If yes, please describe
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Use tobacco? *
Use alcohol? *
Use cocaine or other drugs? *
Wear contact lenses? *
Any allergic reactions to: *
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If you answered Other, please explain
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WOMEN ONLY
Please check all that apply
Please check all that apply *
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If you checked Hepatitis, above, what type?
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ASSIGNMENT AND RELEASE
I hereby authorize payment directly to Precision Dental Group for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by my insurance, and for all services rendered on my behalf or my dependents'. I authorize the doctors, providers or suppliers of Precision Dental Group to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. *
I understand that by filling in my full name below, it acts as my legal signature which authorizes this release.
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